Island Wide Speech Intake Form

Client Information


MaleFemale




YesNo


Spouse/Caregiver #1

Spouse/Caregiver #2


Medical History







Auditory, Speech and Language












Overall Skill Development

Please indicate how you feel about your behavior/development in the following areas:
















Release Forms and Procedures

Authorized Signature Release Form
Please read the Island Wide Speech Authorized Signature Release Form


I agree

Attendance Policies and Sick Procedures
Please read the Attendance Policies and Sick Procedures at Island Wide Speech


I agree

Teletherapy
Please read the Island Wide Speech Teletherapy Consent Form


I agree

Notice of Privacy Practices
Please read the Island Wide Speech Notice of Privacy Practices


I agree

Insurance Information

Insurance Policy Questions

Please read the Insurance Policy Questions to ask your Insurance questions


I agree

Insurance Reimbursement Agreement


I agree

Primary Insurance



MaleFemale

Upload Insurance Card


Secondary Insurance



MaleFemale

Upload Secondary Insurance Card

Upload your Prescription.

Please sign



Island Wide Speech · fara@islandwidespeech.com · (516) 415-2751 · Plainview, NY